The evolution of community psychiatry

Can lessons learned in the long career of Nat Sandler, MD, help us practice better in a reform-driven future?

Not long ago, I attended the winter meeting of the American Association of Community Psychiatrists in Phoenix, a meeting built on the theme of “Innovations in Public Service Psychiatry.” Near the end of the meeting, the moderator, Ken Thompson, MD, invited the audience to share reflections on the conference itself and on the practice of community psychiatry.

After a few individuals rose to speak, the microphone went to Nat Sandler, MD, an unassuming Kentuckian. Nat asked an important question about the future of community psychiatry, but set the stage for it by giving a brief history of his long career in the field. Even more than his question, it was this history that I found striking—and worthy of a story.

Psychiatrist as psychotherapist

From the time he was discharged from the U.S. Navy, Nat Sandler said that he had invested heavily in his career. He was among the first to be awarded a fellowship in community psychiatry and later went on to earn an MPH.

At the start of his career as a psychiatrist, Nat primarily offered dynamic psychotherapy to his patients and, in some cases, he adopted more of an analytical approach. At the time, these were a psychiatrist’s treatments of choice for people diagnosed with mental illnesses. Medications were considered secondary to psychotherapy.

Most of the people Nat saw in the local mental health center in Kentucky had been diagnosed with “neurotic” disorders, plus depression, anxiety, and to a lesser degree, psychotic depression. Most disorders were placed on a continuum between neurotic and psychotic. Mothers were seen as the cause of most problems and were referred to as “schizophenagenic mothers.” Before the advent of lithium, people with bipolar disorders were diagnosed as schizophrenics.

The psychiatrist was the leader of the psychiatric treatment team. The team was made up of psychologists who did testing, social workers who completed histories, and nurses who did traditional nursing duties. The psychiatrist was the primary psychotherapist and diagnostician.

Psychiatrist as prescriber

As time passed and his career continued, Nat found that his role shifted. Medications improved and played a more central role in treatment. The psychologists and the social workers were trained in psychotherapy and could perform it as well as, or in some cases even better than, the psychiatrist could. While the psychiatrist continued to lead the development and direction of the treatment program, Nat found that role of the psychiatrist evolved into that of “prescriber of pills” since the psychiatrist was the only member of the treatment team who could prescribe medications.

With the deinstitutionalization movement, people were released in droves from state hospitals. Talk therapy was no longer the treatment of choice; instead, it took a back seat to medications. This, says Nat, pushed the psychiatrist further into the role of the primary diagnostician and prescriber. At this point, Nat came to feel that his role was even less about treatment and even more about signing off on the treatment plan so the services provided by other roles could qualify for financial reimbursement.

And, in the last seven or eight years, Nat sees that nurse practitioners have gained the ability to prescribe and that psychologists have been authorized to prescribe in two states.

Psychiatry’s role redefined

Before asking his question, Nat spent time in the community psychiatry meeting hearing about how peers are being added to the behavioral health workforce because they are effective at promoting recovery. Though peers have little formal training, he learned that they seem to play an important role on treatment teams because they offer experiences that can be used to help people recover faster. By this point, of course, Nat is beginning to think he can use some peer support himself, since his role as a psychiatrist seems to become more ambiguous all the time!

Fortunately, Nat’s role as a community psychiatrist is being reconsidered and redefined by a group of his peers, including Ken Thompson, Wes Sowers MD, and others. Their plan is to teach psychiatrists how to put recovery principles into practice. To this end, the American Association of Community Psychiatry (AACP) and the American Psychiatric Association (APA) have teamed up to create a new curriculum that prepares their member psychiatrists to continue their essential role, but under a new treatment paradigm: the paradigm of recovery.

Under this approach, psychiatrists are challenged to rediscover their expertise as physicians, helping people not only to battle mental illness with therapy and medication, but to do so in a more holistic way, as people who become and stay physically healthy. This new, more holistic approach will soon prepare psychiatrists to continue and strengthen their roles as physicians who expect to do more than prescribe medications and sign off on treatment plans. Such psychiatrists have a lot to offer in a recovery paradigm and they are preparing to do just that.

Recovery and reform: How can we move forward together?

With healthcare reform on the horizon, all of us are wondering, like Nat and his colleagues, about how our roles will change. The questions for us is not, “What’s next?”, but rather “How can we move forward together, taking with us the skills and roles we know to be effective?”

The advent of the recovery movement—the knowledge that people can recover from mental illnesses—forced us to reassess. We continue to find that what we once tried is no longer true and we’re forced to adopt new approaches. These approaches must go beyond any simplistic paradigms like the medical model versus the recovery model. They are really about taking all that we have learned over the past 70 years and applying it differently in order to bring about the best outcome.